Lung Cytology: Lessons Learned from Errors in Practice

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1 Lung Cytology: Lessons Learned from Errors in Practice Stephen S. Raab, M.D. Department of Laboratory Medicine Eastern Health and Memorial University of Newfoundland, St. John s, NL and University of Washington, Seattle, WA Norsk Forening for Klinisk Cytologi February 3, 2012

2 Overview Cases in which medical error occurred Root cause analysis showed cognitive and technical components Cognitive components reflected biases secondary to criteria and pattern recognition issues

3 Overview Thinking Fast and Slow (Daniel Kahneman) Pattern recognition versus slower, rational thought Heuristics Mental shortcut Pattern of thinking that allows for quick action

4 Overview Recognize cytologic criteria Name three criteria for each case Recognize patterns of criteria and biases that relate to pattern recognition

5 Case 1 The patient is a 45 year old man who presented with a two week history of cough Radiologic studies showed a 2.2 peripherally based mass A fine needle aspiration was performed

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9 Case 1 Original diagnosis: Spindle cell neoplasm, favor fibrous tumor of the pleura versus a malignant mesothelioma Immunohistochemical studies were not performed as little tissue was present on a cell block Three months later, a follow-up chest CT for presurgical staging showed mediastinal adenopathy

10 Case 1 Criteria Spindle cells Uniform nuclei Granular chromatin Patterns Stromal lesion, mesothelial lesion, epithelial lesion

11 Case 1 Correct diagnosis: Atypical carcinoid tumor (neuroendocrine carcinoma) Biases Availability more recent example comes to mind first Recall information in memory drives current process

12 Case 2 The patient is a 61 year old woman who liked chocolate. She presented with shortness of breath and a chest CT showed a 2 cm mass in the right lung A fine needle aspiration was performed

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17 Case 2 Original diagnosis: Adenocarcinoma, poorly differentiated Surgical excision; all lymph nodes benign Pancytokeratin +, vimentin +, all other stains ordered - Eight months later, a follow-up chest CT showed three lesions in the right lung and two in the left lung, ranging in size from 2 cm to 4 cm

18 Case 2 Criteria Large malignant cells Stripped nuclei Hard cytoplasm in areas Large nuceoli Patterns Sarcoma, primary lung cancer, metastatic cancer

19 Case 2 Correct diagnosis: Metastatic adenocarcinoma of renal origin Biases Anchoring tendency to heavily rely on one trait or criterion Expectation disbelieve data that does not conform to opinion

20 Case 3 The patient is a 56 year old woman who had a parrot. She presented with shortness of breath and a chest CT showed a 2 cm mass in the right hilar region Endoscopy showed a raised endobronchial lesion with ucer Bronchial brushing and washing were performed

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25 Case 3 Original diagnosis: Reactive lung; no evidence of malignancy One year later, a follow-up chest CT showed enlargement of the lesion, now reaching 4 cm in diameter

26 Case 3 Criteria Small cells Open nuclear chromatin Thickened nuclear rims No (or dot-like) nucleoli Patterns Reactive bronchial cells, low grade tumor, viral effect

27 Case 3 Correct diagnosis: Adenocarcinoma, well differentiated Biases Neglect of probability disregarding probability (of disease associated with criteria) under uncertainty Confirmation bias search for information that confirms expectations

28 Case 4 The patient is a 58 year old man who had a Norwegian elkhound. He presented with shortness of breath and a chest CT showed a diffuse opacity in the left lung Bronchial brushing and washing were performed

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31 Case 4 Original diagnosis: Reactive changes; no evidence of malignancy Eight months later, a follow-up chest CT showed diffuse opacity

32 Case 4 Criteria Cell clusters Prominent nucleoli Nuclear rim thickening Hard cytoplasm Patterns Reactive changes, well differentiated tumor, viral

33 Case 4 Correct diagnosis: Adenocarcinoma, moderately differentiated Biases Contrast - increase or decreasing a criterion compared to a recently observed contrasting object Do no harm judgment based on desired outcome of no harm

34 Case 5 The patient is a 56 year old man who liked to travel to exotic places. He presented with a cough and a chest CT showed a 2.9 cm mass in the left hilum A transbronchial fine needle aspiration was performed

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38 Case 5 Original diagnosis: Reactive changes; no evidence of malignancy Eight months later, a follow-up chest CT showed no regression in lesion size

39 Case 5 Criteria Cellular Small cells, single and in small groups Granular chromatin Small nucleoli Patterns Inflammation, well differentiated tumor, metastatic tumor

40 Case 5 Correct diagnosis: Well differentiated neuroendocrine carcinoma (carcinoid tumor) Biases Cluster illusion seeing patterns where none actually exist Focusing bias placing too much emphasis on one event and not entire picture

41 Case 6 The patient is a 56 year old man who liked to travel to exotic places. He presented with a cough and a chest CT showed a 2.9 cm mass in the hilum A transbronchial fine needle aspiration was performed

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45 Case 6 Original diagnosis: Negative for malignant cells One year later, a follow-up chest CT an increase in lesion size and additional small nodules (generally less than 1 cm) in both lung fields

46 Case 6 Criteria Cell clusters and single cells Spindled cells and plump cells Low nuclear to cytoplasmic ratios Cytoplasmic tails Patterns Reactive changes, well differentiated tumor, specific inflammatory condition

47 Case 6 Correct diagnosis: Granulomatous inflammation Cultures were positive for acid fast organisms Biases Framing - drawing different conclusions from same information, depending on how information is presented Congruence failure to test alternative hypotheses

48 Case 7 The patient is a 50 year old man who liked spicy hot Mexican food. He had a history of squamous cell carcinoma of the lip with metastasis in the head and neck region. One year later, a follow-up chest CT that showed a 2.5 cm mass in the left hilum A bronchial brushing was performed

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52 Case 7 Original diagnosis: Metastatic squamous cell carcinoma The patient was treated with radiation therapy One year later the lesion had grown in size and a biopsy was performed

53 Case 7 Criteria Squamoid cells Benign lung Mild atypia Rare cells Patterns Reactive changes, primary tumor, metastatic tumor

54 Case 7 Correct diagnosis: Reactive changes The biopsy showed granulomatous inflammation Biases Observer-expectancy observer expects a result and misinterprets criteria to support result Overconfidence

55 Case 8 The patient is a 50 year old man who was seen in the Emergency Department following a car accident. A chest CT showed a 2.2 cm lesion in the left lung A bronchial brushing and washing were performed

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59 Case 8 Original diagnosis: Malignant cells, favor poorly differentiated adenocarcinoma Insufficient material for immunohistochemical studies was available A surgical excision was performed

60 Case 8 Criteria Single cells Large nuclei with prominent nucleoli Pseudoinclusions Hard cytoplasm Patterns Primary carcinoma, sarcoma, metastatic malignancy

61 Case 8 Correct diagnosis: Malignant melanoma Biases Availability Exposure more familiarity with some diagnoses compared to others

62 Case 9 The patient is a 60 year old man who was an art historian. He had a history of malignant melanoma of the back with metastasis to the axillary lymph nodes. On a follow-up chest CT a 2 cm mass was seen in the left upper lobe A bronchial brushing was performed

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66 Case 9 Original diagnosis: Malignant melanoma Immunohistochemistry studies were not performed Two years later, the patient died and an autopsy was performed

67 Case 9 Criteria Single cells Multi-nucleated cells Nuclear rim thickening Eccentric nuclei Patterns Metastatic malignancy, primary malignancy

68 Case 9 Correct diagnosis: Poorly differentiated adenocarcinoma Biases Observer-expectancy Wishful thinking bias making decisions based on what one wants to see instead of evidence

69 Case 10 The patient is an 81 year old woman who had a history of serous papillary carcinoma of the ovary. She presented with shortness of breath. A chest CT that showed a pleural effusion A bronchioaveolar lavage was performed

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73 Case 10 Original diagnosis: Metastatic adenocarcinoma

74 Case 10 Criteria Cell clusters Prominent nucleoli Variable cell size Finely granular chromatin Patterns Metastatic malignancy, primary malignancy

75 Case 10 Correct diagnosis: Adenocarcinoma, with bronchioalveolar features Biases Framing Focusing

76 Case 11 The patient is a 59 year old man who smoked Cuban cigars. He presented with chest pain and shortness of breath. A chest CT showed a 2.1 cm mass was seen in the right upper lobe A fine needle aspiration was performed

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81 Case 11 Original diagnosis: Non-small cell carcinoma

82 Case 11 Criteria Single cells Stripped nuclei Granular chromatin Crushed nuclei Patterns Malignancies of various types

83 Case 11 Correct diagnosis: Small cell carcinoma

84 Case 12 The patient is a 47 year old woman who uses an inhaler for asthma. A chest CT showed an ill defined opacity in the right lower lobe A bronchial washing was performed

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90 Case 12 Original diagnosis: Adenocarcinoma Immunohistochemically, the cells were reactive for cytokeratin 7 and TTF-1 A surgical excision was performed

91 Case 12 Criteria? Patterns?

92 Case 12 Correct diagnosis: Reactive changes Biases?

93 Case 13 The patient is a 50 year old man who was a tobacco user. He had a history of small cell carcinoma that was treated with chemotherapy and radiation therapy. A follow-up CT showed a 1.6 cm left hilar lesion A bronchial brushing was performed

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98 Case 13 Original diagnosis: Reactive changes

99 Case 13 Criteria? Patterns?

100 Case 13 Correct diagnosis: Squamous cell carcinoma Biases?

101 Case 14 The patient is a 38 year old man who runs marathons. He began experiencing weakness and difficulty breathing. A chest CT showed an anterior mediastinal 4 cm mass and a 2 cm mass in the left lung A fine needle aspiration of the lung mass was performed

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106 Case 13 Original diagnosis: Atypical lymphoid cells, cannot rule out lymphoma

107 Case 14 Criteria? Patterns?

108 Case 13 Correct diagnosis: Thymoma Biases?

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